by Dr Edwin Kruys

Social determinants of health: Why I am all tip and no iceberg

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, send an email, contact me via social media or leave a comment below. Melissa Sweet suggested the topic of this post: ‘Social determinants of health’. She tweeted: “Interested in your take on SDOH & how they play out locally.” Thankfully, to make the task easier, Melissa suggested some background reading: 436 articles from the Croakey archives.

Note: ‘Social determinants of health’ are economic and social conditions that influence the health of people and communities.

“Doc, that’s not going to work.” The health worker was standing behind me. She had overheard my consultation with the elderly man. I thought I was doing a great job, as I had taken the time to explain what diabetes was all about – in layman’s terms – and how he should inject the insulin.

The indigenous health worker continued: “He lives mostly outside and keeps his medications under a tree.” I couldn’t believe what she had just said. When the penny dropped I realised she was, of course, right: the insulin wouldn’t last in the excessive heat of the Kimberley.

It was clear that I had no idea of my patients’ living circumstances. I felt like a fool.

The home visit

Another time, another place. I was doing a home visit in a Cape York indigenous community as part of a team consisting of two nurses, a social worker, a health worker, a police officer and a local government representative.

The verandah was covered with rubbish and furniture. It was hot inside. The room was empty, apart from a few mattresses. The concrete floor and walls were dirty. “How many people live here?” I asked. “Between 8-20, depending on when you visit,” said the social worker.

The patient was lying on a mattress – she clearly only had a short time to live. There was not much I could do apart from some small medication changes. Afterwards, we had a long chat on the verandah about fixing the air-conditioning and the tap, and making her last days as comfortable as possible.

All tip and no iceberg

The contribution of doctors and other health care professionals to our wellbeing is relatively small: Depending on what source you read, healthcare contributes for about 25 percent to our health. On the other hand, an estimated 50 percent of our health is determined by economic and social conditions (see image).

One of Australia’s leading researchers on the economic and social determinants of health is Professor of Public Health Fran Baum. “Typically,” she writes in this editorial, “responses to diseases and health problems are knee jerk and concerned with ameliorating immediate and visible concerns.”

Professor Baum calls this the ‘all tip and no iceberg’ approach. Instead of focussing on disease and unhealthy behaviours we should improve the conditions of everyday life.

To combat the chronic disease and obesity epidemic for example, we should not just be advising lifestyle changes and initiating medical treatment. These are tip-of-the-iceberg solutions.

Instead, says Baum, let’s look below the surface at things like urban planning, the availability of unhealthy food, our sedentary lifestyles at home and at work, and equal opportunities for all.

Image: About 50% of our health is determined by economic and social conditions (green). Source: Adapted from a presentation by Professor Fran Baum

General practice

In my work the influence of economic and social factors is apparent. Some examples:

The 26-year old single mother who cannot afford medications for her children

The 38-year old machine operator who gained 10 kg of weight since he started a fly-in-fly-out job in a remote mining community

The 50-year old chief executive who makes 14-hour days in a high-pressure environment, and develops anxiety symptoms.

My role as a GP in these scenarios is modest. Ok, ‘all tip and no iceberg’ may be too harsh – apart from the fact that it sounds like ‘all icing and no cake’…

But Professor Baum has an important message: We must not close our eyes to what really makes us ill and, more importantly, change it.